5 BALCOMB ST - BP APP 17-61 REMODEL K&B Q The Commonwealth of Massachusetts
�Q Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'a edition
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Building Permit Application To Construct, Repair, Renovate Or Demolis
One- or Tyro-Fmrtih Duelling
This Section For Official Use Only
Building Permit Num r: Date Applied:
Signature:
Building ommissionce Inspector of guildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map dt Parcel Numbers
_� �LCc�sY)t� sr
1.la Is this an accepted street'!yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distuct Proposed Use Lot Area(sq R) Frontage(it)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system (3
Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
.l Qwner)A of ,or A 60tr S
Name(Pr' t) Address for Service:
Signal Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Cons ruction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alleration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Unita_ Other ❑ Specify:
Brief PTsf ription of Proposed Work-: �' ayU
opr
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OfBelal Use Only
Lahor and Materials
1. Building f I. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical f ❑Total Project Cost(Item 6)x multiplier x
). Plumbing f 2. Other Fees: f
4. .Mechanical (HVAC) f List:
5 .Mechanical (Fire f
re Total All Fees: f
Su ssion
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: f .COD-0 0 13 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
'' . - Liccme Number Expiration Date
N;poe tit CSL Hylder Lot CSL Type bcc below)
Type Dcscn non
Address
U Unrestricted 1 up to 35,000 Cu. Ft.
R Restricted 1&2 Family D%ellm
Signature .M %lasonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O No........... O
rSEN OWNER AUTHORIZATION TO BE COMPLETED WHEN
GENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�T Pft 1A (,nyyj e Y as Owner of the subject property hereby
to act on my behalf,in all matters
authorized by this building permit application.
er Date
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
, as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will I [have access to the arbitration
program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I01R6 and 110.R5.respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/ porches
Typeof cooling cystem Enclosed Open
1. "Total Project Square Footage' may be+uhstituted for 'Total Project Cost"
1 ,
CITY OF &kL.EIM
PUBLIC PROPERTY
DEPARTMENT
�f01F1liY n�wvv L
NwV 130 WADMIG'ON S4U"0&MAK M. AS&AO/ISWM 0t9?0
Txi r..47tS•9S"• F.Uc 971040.994
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location
Home Owner Address 6)93 cb�nCS r
Home Owner Telephone 9`7 F F7YS4 d 81
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family dwellin& attached or detached.
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner•'assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and req irements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTO
See other side for state code
r�s
CITY OF SALLM
PUBLIC PROPRERTY
' DEPARTMENT
Construction Debris Disposal Al'lida% it
(reyuircd li/r all demolition and rcnocation work)
In accordance \\itll the sixth edition ul the State Building Code, 780 CTIR section I 11 5
Dcbris, and the provisions of:NIGL c 40, S 54;
Building Permil h is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The dch'is will be transported by:
sir s�����^ � r
(name ul haular)-S_
I he debris will be disposed ot'in
Yi 'tC/
tamr ul laulny)
1•Iddres. rd'l�nlnyl I ^I AI /AI //r^1/I
iaWlc nt p:Hurt .y+phcant